Friday, October 31, 2014

Q:What are the 2 major kinds of Dialysates used in
CRRT?

Answer:

1. Lactate
based Dialysate
solution

2.8.4%
bicarbonate based dialysate

Lactate is commonly used as buffer.
In conditions where inadequate lactate metabolism takes place (eg. in liver
failure) the bicarbonate based dialysate is preferred. However, recent studies
suggest that bicarbonate-buffered replacement fluids can improve acid-base
status and reduce cardiovascular events better than lactate
fluids. Both fluids should contain
electrolytes in concentrations aiming for a physiologic level and taking into
account preexisting deficits or excess and all input and losses.

Sunday, October 26, 2014

Q:Which anti-epilectic drug can be use as an antidote in Tacrolimus
Toxicity?

A)
Phenytoin

B) Levetiracetam,

C)
Carbamazepine

D)
diazepam

E)
Toprimate

Answer:
A

Tacrolimus is metabolized by the
CYP3A4 isoenzyme. Tacrolimus is subject to numerous drug-drug interactions.
CYP3A4/PGP inhibitors may increase tacrolimus concentrations, whereas inducers
may decrease tacrolimus concentrations. Phenytoin and Phenobarbital are commonly used
antiepileptics and potent enzyme inducers. Another well known inducer is
Rifampin.

Wednesday, October 22, 2014

Q:What is the mean level of Troponin I elevation in Subarachnoid Hemorrhage (SAH)?

Answer:0.93

At least one study showed that the mean troponin level in subarachnoid hemorrhage was 0.93 (range, 0.01-25.8 ng/mL). But, Troponin I elevation after SAH is not an independent predictor of in-hospital mortality.

Monday, October 20, 2014

Q: Fluoroquinolones are of considerable clinical importance because of their ability to cause prolongation of the QT interval and consequently causing Torsades de pointes (TdP). Which Fluoroquinolone is known to be the least and which Fluoroquinolone is known to be the worst offender?

Sunday, October 19, 2014

Q: Which one group of antibiotics (other than Vancomycin) has shown to increase the risk of Vancomycin-resistant Enterococcus (VRE)?

Answer:Cephalosporin

Use of Cephalosporin has been found to increase the risk for colonization and infection by VRE. Restriction of cephalosporin usage has shown to be associated with decreased VRE infection and transmission in hospitals.

Friday, October 17, 2014

Tetanus is caused by tetanospasmin which is a neurotoxin.Its a rare entity in developed world. History of wound and possible contamination in unvaccinated individuals is classic. Tetanus is characterized by a clinical triad of rigidity, muscles spasms, and, in more severe cases, autonomic dysfunction.The characteristic presentation of tetanus is muscle rigidity and spasms.Jaw stiffness followed by spasms of jaw muscle is called trismus is characteristic of tetanus.Muscle spasms are progressive and may include a characteristic arching of the back known as opisthotonus as seen in the video.The spasm are triggered by any sort of stimuli. The disease can involve spasms of the vocal cords leading to respiratory failure.

Patient should be placed in restful environment with quietest possible conditions. Sedation, paralysis with curare like agents and mechanical ventilation are mainstay of therapy. Penicillin,20 MU intravenously in daily divided dose help eradicate toxins.

Thursday, October 16, 2014

Q:What is the basic physiology which allows Pulmonary Artery Catheter (PAC) (swan-Ganz catheter) to measure left atrial pressure while catheter is still in pulmonary artery?

Answer:It is the large compliance of the pulmonary circulation, which allows an indirect measure of the left atrial pressure, while catheter is still in pulmonary artery. When balloon is inflated (wedged) in pulmonary artery, it occludes the branch of the pulmonary artery. When this occurs, the pressure in the distal port of PAC rapidly falls, and after several seconds, reaches a stable lower value that is very similar to left atrial pressure (normally about 8-10 mmHg).

Wednesday, October 15, 2014

“Berlin definition” of ARDS is a consensus panel's new definition and severity classification system for acute respiratory distress syndrome (ARDS). It aims to simplify the diagnosis and better prognosticate outcomes. It was published in JAMA, online May 21, 2012. It took into account cohort of 4,400 patients from past randomized trials. Major departure from 1994 classification of ARDS was, there is no need to exclude heart failure in the new ARDS definition. Patients with high pulmonary capillary wedge pressures can still have ARDS. The new criterion is that respiratory failure simply be “not fully explained by cardiac failure or fluid overload,” in the physician’s best clinical judgment. An “objective assessment“– meaning an echocardiogram was highly recommended. The new Berlin definition for ARDS would also categorize ARDS as being mild, moderate, or severe:

Mild is P/F ratio of 200 – 300 with predicted mortality of 27%

Moderate is P/F ratio of100 – 200 with predicted mortality of 32%

Severe is P/F ratio less than 100 with predicted mortality of 45%

In 'Berlin definition', clinical variables that are widely believed to be important such as static compliance, radiographic severity and PEEP more than 10 — were not predictive of mortality or other clinical outcomes.The panel’s findings, endorsed by the European Society of Intensive Care Medicine, the American Thoracic Society (ATS) and the Society of Critical Care Medicine (SCCM), emerged from meetings in Berlin to try to address the limitations of the earlier AECC definition.

Sunday, October 12, 2014

Q:52 year old male with ESRD is admitted to ICU with
septic shock. Patient is started on CRRT. Patient has previous history of A.fib.
Pt. went into RVR (Rapid ventricular rate). Cardiology service started IV
amiodarone. Is Amiodarone dialyzable?

Answer:No

Amiodarone is eliminated primarily
by hepatic metabolism and biliary excretion. Desethylamiodarone (DEA) is the
major active metabolite of amiodarone. Neither amiodarone nor DEA is dialyzable.

Thursday, October 9, 2014

Q:
What is the recommended target for blood sugar control in fresh post-op cardiac
surgery patients?

Answer: The
Society of Thoracic Surgeons supports a target glucose of less than 180 mg/dL
using intravenous insulin for at least the first 24 hours postoperatively, with
a target of less than 150 mg/dL if their ICU stay exceeds 3 days because of comorbidities.

Wednesday, October 8, 2014

Q: At
what point, during management of DKA (Diabetes Ketoacidosis), addition of
Dextrose should be considered, if ketosis persists?

Answer: 250
mg/DL

The 2011 'Joint British Diabetes
Societies guideline' recommends the intravenous infusion of insulin at a
weight-based fixed rate until ketosis has subsided. Should blood glucose fall
below 250 mg/dL, 10% glucose should be added to allow for the continuation of
fixed-rate insulin infusion.

Tuesday, October 7, 2014

Diagnosis of Boerhaave syndrome is
difficult as about one third of all cases of Boerhaave syndrome are clinically
atypical. Even with clinical signs, Boerhaave syndrome is
usually misdiagnosed as acute myocardial infarction, pancreatitis, pleuritis,
pericarditis, Aortic dissection or pneumothorax etc. Radiographic studies should
be promptly obtained.

Overall mortality is estimated to be
around 35%, making it the most lethal perforation of the GI tract. The best
outcomes are associated with early diagnosis and definitive surgical management
within 12 hours of rupture. If intervention is delayed longer than 24 hours, the
mortality rate rises to higher than 50% and to nearly 90% after 48 hours. Left
untreated, the mortality rate is close to 100%.

Sunday, October 5, 2014

Q:On which day after initiation of empiric antibiotic therapy, de-escalation should be considered?

Answer: 3 - 5 days

For patients who have suspicion of infection, early and appropriate therapy - and probably aggressive empirical therapy - is required at the first sign of infection. Although, the initial choice of antimicrobial therapy is critical to the clinical outcomes of patients, it is also imperative to start de-escalation of antibiotics therapy as emerging data is showing benefit in mortality rate, or at least no worse outcome.

De-escalation therapy based on APACHE II score can be safely applied with good clinical outcomes, even in those patients with negative cultures.

Saturday, October 4, 2014

Critically ill patients placed on enteral nutrition (EN) are usually underfed as most of them are placed on "Frequency-based Enteral nutrition" (FBF). Interruptions are frequent due to various reasons. A "volume-based feeding" (VBF) allows to adjust the infusion rate to make up for interruptions in delivery. Studies have shown that VBF strategy is safe and improves delivery to better meet caloric requirements than the standard more commonly used frequency-based strategy.

Friday, October 3, 2014

Q: What is the rule to remember if blood type compatibility is done for plasma products?

Answer:

Compatibility testing is not strictly necessary for plasma products like FFP or cryo-precipitate, but if possible, is given as ABO compatible. Rule to remember is - compatibility is reversed for plasma products, means O type is the universal plasma recipient and AB type is the universal plasma donor.

Wednesday, October 1, 2014

"A 58-year-old Asian man with no history of cardiac disease, hypertension, or diabetes mellitus had an AMI and subsequent cardiogenic shock. He was started on dopamine and norepinephrine and transferred to a tertiary care center for rescue percutaneous coronary intervention (PCI). Given that his artery was patent with Thrombolysis In Myocardial Infarction 3 flow, PCI was not attempted. He had an ejection fraction of 25% and mid-distal anteroseptal akinesis. He was transferred to the intensive care unit on intra-aortic balloon pump (IABP) support. The patient’s condition continued to deteriorate, and an Impella LP 2.5 pVAD was inserted for additional hemodynamic support and as a bridge to definitive revascularization. To reduce the potential for medication error and decrease the patient’s bleeding risk, the purge solution was changed to 20% dextrose injection without heparin and continued at a rate of 15 mL/hr. The patient’s hemodynamic values improved, and the pVAD and IABP were continued for the next five days. The patient was successfully anticoagulated with i.v. heparin throughout the remainder of pVAD support. While the patient did develop hemolytic anemia during his device support, there were no thrombotic or bleeding complications."